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I APF.+ PATE: PImIlowlF ralifornia Department of Public HP^Ith Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 OFFICE USE ONLY NOTE: Use one form for each pump or multiple pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sectior: 116064.1 and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner c a public swimming pool shall file this form within 30 days following the completion of construction or installation of at,f entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Buildin Department for any necessary plan approval and permits prior to construction or remodel. Site Information C ' Facility Name: IQ VA 1-1-13 �I NIV 5 W (Ti -5 Pool Identification if more than 1 pool/spa at site): Facility Address: Ih'8 LAN ROAD city: A fHgoJ! St_(�AZip: qS�3 Owner Name: - Owner's Phone Number..2CRq•S2g` I;, -:2Z( Ov✓ners Address City _ SL Zip Pool constructed on or after January 1, 2010?: ❑ Yes o No Pump Information ❑ Recirculation P Ti Jet / Booster Pump Make/Model � , f34f= H.P I• Make/Model V_ 171612- H.P 1 •5 ❑ Other Pump: ❑ Feature Pump Make/Model -H. P Make/Model • H.P Manufacturer of approved drain cover. GPM rating: Floor 206 OT'iriv Manufacturer of approved drain cover. Installed on Model Number: Ifl aV—X Install date )j9.Floor ❑ Wall J46/C6 Model Number: Install date GPM rating: Floor Wall Installed on ❑ Floor ❑ Wall Main drain/Jet suction pipe size is �_ inches. Check One: X Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) o Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) ❑ Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agent Type of secondary device Installed: Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 o ASME/ANSI standard A 112.19.17 I declare that I hold an active California State Contractor license # L with classification or a California State Professional Engineer license # with qualified experience wo ing on public swimming pools and that the information provided above is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Name: �fhG0 C - �A 20 ((� Company Name: M (G U r L [] S _-RL' I CF & Company Address: t"' 8 3 D'f. City M 19 N1 r rA State: If r f Zip Code: 9 533 Contractor/Engineer PhoneNumber:Qd6Cell Phone Number. -2o!1 -2 Contractor/Engineer FAX Number: Email: /_V IS M I riIFL 6ARic (R Contractor/ Engineer name (PRINT) ractor gine For a complete text of the law, visit: hftp:/rinfo.sen.ca.gov/pub/09-10/billiasmiab_ .2Q )-.2H sr name (SIGNATURE) ` . Date 1 0 01-1 0 501 ab_1020_b i l 1-20091011_ch aptered. pdf